Provider Demographics
NPI:1114984168
Name:WEITZ, MICHAEL JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEFFREY
Last Name:WEITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12079
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-3852
Mailing Address - Country:US
Mailing Address - Phone:562-809-3595
Mailing Address - Fax:562-468-0347
Practice Address - Street 1:1328 TWENTY SECOND ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2091
Practice Address - Country:US
Practice Address - Phone:310-582-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57330207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G573300Medicaid
E83077Medicare UPIN
CAWG57330FMedicare ID - Type Unspecified